Achievements and future of the global aids response Peter Piot Imperial College London

Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

Decline in adult mortality with introduction of ART: Botswana

HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region) Southern Africa Median HIV prevalence (%) 50 Botswana Lesotho Mozambique Namibia South Africa Swaziland Zimbabwe 1997– – West Africa Median HIV prevalence (%) Median HIV prevalence (%) Eastern Africa 1997– – – – Ethiopia Kenya Burkina Faso Côte d'Ivoire Ghana Senegal 2.9 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS. July 2008.

Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004– Number of HIV-positive pregnant women receiving anti-retrovirals Year % of HIV-positive pregnant women receiving anti-retrovirals Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries. 4.13

AIDS IS NOT OVER

HIV prevalence (%) in adults (15–49) in Africa,

HIV infections among men having sex with men in Asia

How did we get there? » Science and rights driven » Political approach » A global response » Focus on results for people » Prevention AND treatment » Multi-disciplinary, multi-sectoral » Community engagement

People living with HIV 2007‘01‘02‘03‘04‘05’06‘94‘95‘96‘97‘98‘992000‘87‘88‘89‘90‘91‘92‘93 Millions 1980‘81‘82‘83‘84‘85‘ First cases of unusual immune deficiency identified HIV identified as cause of AIDS First regimen to reduce mother-to-child transmission of HIV First HIV antibody test becomes available Highly Active Antiretroviral Treatment WHO launches the Global Programme on AIDS Global Fund to fight AIDS, Tuberculosis and Malaria US$10 billion for AIDS in developing countries UNAIDS created President Bush announces PEPFAR 3 million on ART in developing world The UN General Assembly Special Session on HIV/AIDS Four Frees and One Care

[i] data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996) Notes:[1] figures are for international funds only [2] Domestic funds are included from 2001 onwards Total annual resources available for AIDS 1986‒ US$ million billion Signing of Declaration of Commitment on HIV/AIDS, UNGASS ‘96‘97‘98‘99‘00‘01‘02‘03‘04‘051986‘87‘88‘89‘90‘91‘92‘93‘94‘95 Less than US$ 1 million World Bank MAP launch Global Fund PEPFAR 257 UNAIDS Gates Foundation ‘ billion 10 billion

Treatment Action Campaign (TAC), South Africa

Recorded female deaths in South Africa and Brazil for ages years Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica. Brazil, 2004.South Africa, 1997.South Africa, 2004

A global response Human rights and strategic issue/smart power Global public good Role of United Nations Global civil society and activism International financing Generation WE

UN security Council Resolution 1308 (2000) on AIDS

New instruments for AIDS financing World Bank Multi-country AIDS Program (2000) Global Fund to Fight AIDS, TB and Malaria (2002) PEPFAR, (2003) Unitaid (2005) (PRODUCT) Red (2005) Debt2Health (2007)

Disbursements for HIV per US$ 1 Million GDP, 2006 H Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April Italy 4 Japan 24 Canada 50 Germany 60 France 93 United States 120 United Kingdom 328 Ireland 408 Sweden 462 Netherlands US$

Prices (US$/year) of first-line antiretroviral regimen in Uganda:

Focus on results for people  Targets  Know your epidemic and the society  Monitor and evaluate  Invest in information systems

Know your epidemic

A multi-disciplinary, multi-sectoral response Health outcomes determined by multiple factors and interventions Particularly key besides health: law, education, work place, trade, armed forces Need to expand resource base First genuine business engagement in health

Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets 6.5 Source: UNGASS Country Progress Reports Public works Tourism Trade and industry Minerals and energy Agriculture Transportation Health Labour Military/police Sector included Earmarked budget present Percentage of countries (%), N=126

Community engagement From planning to implementation Makes or breaks programmes “Aids literacy” National Aids Councils and Global Fund Country Coordination Mechanisms Societal sustainability and resilience

TASO, Uganda

Opportunities for global health  Health diplomacy  Increased funding (ODA and research)  Collateral benefits (TB,malaria, health systems)  Culture of accountability  Tiered pricing  Engagement of non-medical sectors  Boost to research  Major interest by young people

Challenges: the long term view A still changing epidemic Sustainability (leadership, funding, treatment) An all out effort on hiv prevention Links and synergies with health and development Improve programme delivery and capacity R&D

Number of HIV infections each year by route of transmission in Cambodia, Source: Peerapatanapokin and Brown, using Asia Epidemic Model Number of new HIV infections each year by route of transmission in Cambodia, (Source: Peerapatanapokin and Brown, using Asian Epidemic Model) Male clientsSex workersWife from husbandHusband from wifeMother to child

Estimated Resource needs for AIDS, TB and malaria (2009 to 2015) Sources: UNAIDS, STB, RBM

Annual resources available 2000–2007 and funding gap between projected financial resources if current scale-up continues and a phased scale-up scenario to reach universal access between 2010 and 2015 (US$ billion) I US$ Billion Resources available for HIV services Resource Needs: if current scale-up continues Resource Needs for phased scale-up to Universal Access

Total health ODA commitments, US$ Billions

The PREVENTION GAP Persons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007

Direct funding of health systems through Global Fund grants Amount (approximately) Commodities, Products, Drugs - $6.3-billion Health Systems - $4.9-billion Administration - $1.4-billion Other - $1.4-billion

Cost Effectiveness

aids2031 Taking a long term view- stretching planning and funding horizons to achieve sustainability Multi-disciplinary – bringing together bio-medical, social and political scientists, economists and activists to look at what should we do differently – or more of the same – now to change the future of AIDS Key aids2031 report “Agenda for the Future” to be launched end of 2009

CONCLUSIONS Science AND justice as basis for policy Nothing for the people without the people Genuine multi-disciplinarity Information for accountability and programming Think long term No magic bullet!